Increasing Access to Medications and Devices for the Care of Low-Risk Childbearing Families: An Analysis of Existing Law and Strategies for Advocacy

Limited access to medications and devices relevant to the care of low-risk childbearing families acts as a barrier to the successful integration of high-quality midwifery care into health care systems. Families who live in clinically underserved areas, whether urban or rural, are particularly in need of perinatal professionals who can provide comprehensive care. This article reviews existing US laws that impact whether families who choose community-based care with direct entry midwives have access, through their chosen provider, to the medications and devices relevant to their normal perinatal and postpartum care. Scope of practice and practice authority are considered as they relate to access to medications and devices primarily for certified professional midwives and state-licensed midwives. These professionals are the primary health care providers offering community-based care and birth at home and in freestanding birth centers. Washington state laws are compared and contrasted with laws from other states and jurisdictions, with the aim of identifying ways to improve service delivery for families who choose community-based midwifery care. Recent and historical efforts to expand Washington state's midwifery drugs and devices formulary are described. This discussion outlines the Washington context for direct entry community midwifery practice, highlights relevant legal examples, and describes current and future efforts around quality improvement. Information from a midwifery clinic serving some of Washington's most vulnerable pregnant and postpartum families allows for an exploration of the role that access to essential medications and devices might play in supporting midwives to address health inequities. Ideal statutory and regulatory language, lessons learned from an analysis of Washington's experience, and strategies to overcome barriers are described to aid and inspire midwifery advocates in other jurisdictions who want to increase access and enhance their ability to offer current evidence-based care. Policy makers can improve health, health equity, consumer choice, and access to evidence-based care by using ideal legal language for midwifery practice authority.

Neuronal pathways from the dorsal ocelli of the house cricket, Acheta domesticus

Each ocellar nerve in the house cricket Acheta domesticus contains giant nerve fibers of 10--15 mum diameter, characterized in Golgi-Cox preparations by a single row of short collaterals which runs along nearly the entire length of a fiber. Numerous long collaterals are given off by thin fibers in the ocellar nerve; medium-size fibers give off relatively few collaterals. The lateral ocellar tracts extend posteriorly through the dorsal protocerebrum, crossing the protocerebral bridge dorsally. The smaller median ocellar tract runs more ventrally through the pars intercerebralis; posterior to the bridge its fibers turn out toward the lateral nerves. Golgi and cobalt preparations reveal branching of giant and medium-size ocellar fibers posterior to the bridge at two levels, forming bilateral regions of ocellar neuropile. No ocellar processes appear to be given off to the corpora pedunculata, central body, nervi corporis cardiaci, antennal lobes, or circumesophageal connectives; it is uncertain whether ocellar collaterals extend into the protocerebral bridge or optic lobes. Cell bodies of giant and medium-sized fibers are located in the pars intercerebralis.